60 NCCN Guidelines for Patients ® : Melanoma, 2018 5 Treatment guide Regional melanoma Regional melanoma Guide 12 shows the treatment options for stage III melanoma, also called regional melanoma. Primary treatment is the main treatment used to rid your body of cancer. Adjuvant treatment is additional treatment given after the main one to try to kill any remaining cancer cells and lower the chance of cancer recurrence (return). See Part 4 on page 35 to get details on each type of treatment listed in the chart. For pathologic stage IIIA, IIIB, and IIIC melanoma that was upstaged based on the sentinel lymph node biopsy, the tumor has already been removed. Therefore, the primary treatment options are to closely watch the active lymph node basin (usually with ultrasound studies) or have a complete lymph node dissection, although additional lymph node surgery has not been shown to improve overall survival. After primary treatment, there are five options that may be considered for adjuvant treatment. You can begin observation; receive nivolumab if stage IIIB or IIIC (preferred adjuvant immunotherapy); receive dabrafenib and trametinib if you have a BRAF V600–activating mutation and sentinel lymph node metastasis >1 mm; receive high-dose ipilimumab for sentinel lymph node metastasis >1 mm; or receive interferon alfa (either 1 year of high-dose interferon or up to 5 years of the pegylated form of interferon). Observation without systemic therapy but with imaging surveillance is an option for surgically removed melanoma in the lymph nodes. With or without adjuvant treatment, all patients are observed for a period of scheduled follow-up testing to watch for cancer spread (metastasis) or return (recurrence). For clinical stage III melanoma, primary treatment with wide excision of the primary tumor and complete therapeutic lymph node dissection is an option. Adjuvant therapy includes local treatment using radiation. This is only for certain patients that are at high risk of the cancer spreading further into the lymph nodes. For systemic treatment, you can begin observation, receive nivolumab (preferred adjuvant immunotherapy), receive dabrafenib and trametinib if you have a BRAF V600–activating mutation, or receive high-dose ipilimumab, interferon alfa, or biochemotherapy. Biochemotherapy is combination treatment with chemotherapy and immunotherapy. It is a very strong treatment and may not be a good option for everyone. Observation is another option. For stage III clinical satellite or in-transit melanoma, primary treatment includes many options, including clinical trials. The first is systemic therapy for metastatic or unresectable melanoma. The next option is surgery to remove the tumor(s) with negative margins. Negative margins means there are no cancer cells in the normal-looking tissue around the edge of the tumor removed during surgery. Your doctor may also consider doing a sentinel lymph node biopsy during surgery since it is likely that the cancer has spread. If the entire tumor can’t be removed with surgery, there are other treatment options. Local therapy options include T-VEC, BCG, interferon alfa, or IL-2 injections into the tumor or imiquimod cream rubbed onto the tumor. These are immunotherapy drugs and may be good options if you have clinical satellite or in-transit metastases. Your doctor may consider palliative radiation to relieve symptoms if the cancer can’t be removed by surgery.